Download ULTRA- SOUND DIAGNOSTIC X

To Schedule: Call or Fax
Laguna Niguel/Mission Viejo
Appt:_ _____________
PATIENT’S NAME:__________________________ DOB:______________________
Phone:_________________________________ Cell:_ _____________________
 Diagnostic Imaging • (949) 272-2200 Fax: (949) 753-9030
 Breast Imaging • (949) 753-9090 Fax: (949) 753-9030
Referring Physician:_________________________ Phone:_____________________
 Diagnostic Imaging • (949) 753-0900 Fax: (949) 753-1719
 Breast Center • (949) 753-9090 Fax: (949) 753-9030
 PET/CT • (949) 753-0362 Fax: (949) 753-8153 For interpretation, please provide all correlative CT, MRI, and PET/CT films at time of service.
Irvine
Physician Address:___________________________________________________
Santa Ana / Tustin
Santa Ana / South Coast
Clinical History / Diagnosis (Required):_ _____________________________________
_ _____________________________________________________________
_ _____________________________________________________________
_ _____________________________________________________________
Anaheim
Duplicate Report To:__________________________________________________
 Diagnostic Imaging • (714) 835-6055 Fax: (714) 835-2507
 Breast Center • (714) 543-9927 Fax: (714) 543-5883
 Diagnostic Imaging • (714) 966-0904 Fax: (714) 966-0972
 Diagnostic Imaging • (714) 300-0703 Fax: (714) 300-0704
Physician Signature:______________________________________________________ Date Signed:___________
 STAT
NOTE: Reports and images also available on RIS/PACS Physician Portal
 CALL REPORT
 FAX REPORT
 FILMS W/PATIENT
 FILMS W/REPORT
IMPORTANT (See Special MRI Screening on reverse side)
MRI
OPEN MRI offered at
Santa Ana/Tustin
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Brain
Pituitary
Soft Tissue Neck
MR Angiography (MRA)
Region: ____________
 With 3D Rendering
 Exam without contrast
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 Exam with contrast
Abdomen  Pelvis  Both
Extremity Rt / Lt / Bilat
___________________
Spine  C  T  L
MR Arthrography
 IMAGES ON CD
 Exam with and without contrast
MRI Breast
 Evaluation of Implants
 Evaluation for Breast Cancer
 MRI Guided Breast Biopsy
 Other:______ _________________
Creatinine/BUN required for: CT within 90 days, MRI within 45 days if patient > 60, has renal insufficiency, diabetes, or hypertension.
 Lab: Will send with patient  WCRC to perform at the time of diagnostic exam
CT
PET/CT
ULTRASOUND
BREAST
IMAGING
NUCLEAR
MEDICINE
Offered at
WCRC - Santa Ana /Tustin
DIAGNOSTIC
X-Ray
 Exam without contrast
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Brain
Sinuses
Temporal Bones (Mastoids)
Soft Tissue Neck
Spine  C  T  L
Other:_______________________
 Exam with and without contrast
 CT Angiography _ ________________
 CT Urogram
 CT Enterography
 Chest
 Nodule  High Res
 Abdomen  Pelvis  Both
 Extremity Rt / Lt
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
CT Health Screen
 Coronary
 Full Body
 Lung
 Virtual Colonoscopy
With 3D Rendering
Exam Purpose:  Initial Treatment Strategy
 Subsequent Treatment Strategy
 78815 - Skull Base to Mid-Thigh 78816 - Whole Body (Indicated for Melanoma)  78608 - Brain (indicated for Alzheimer’s)
Please complete CT Section Only When adjunct CT is ordered in addition to PET/CT.
 OB
 0-14 weeks  14 weeks or more
 Carotid Doppler
Breast

Arterial
 Upper  Lower  R.  Lt.  Bilat
 Soft Tissue Neck / Thyroid
Abdominal
 Venous  Upper  Lower  R.  Lt.  Bilat
 Testicular
Renal
 Other: _ _______________________________ Pelvis
 Pelvis Ltd.-Pre and Post Void Bladder Only  Pelvis Complete - Gynecologic Exam  Hysterosonography (HSG)
 Right
 Left
 Both
 MRI Breast
 Ductogram
 DEXA
 MRI Guided Breast Biopsy Rt / Lt
 Sono Guided Cyst Aspiration
 Screening Mammogram
 Wire Localization for Surgical Excision
 Sono Guided Minimally Invasive Breast Biopsy  Mammo Guidance
 Diagnostic Mammogram
 Stereo Guided Minimally Invasive Breast Biopsy  Sono Guidance
 Breast Ultrasound
 Bone Scan:
Whole Body
Limited
W 3-Phase
WSPECT
Region: ________________________
 Myocardial Perfusion Stress/Rest w/ EF:
 Renal Scan:
 Hepatobiliary Scan:  W CCK
 W/O CCK
 Lung Ventilation/Perfusion
 With Differential Quantification
 Thyroid Scan & Uptake
 Other:______________________________________________
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X-ray ( Rt  Lt)
 Body Part ______________________
Irvine: Only Chest X-ray and other limited studies.
PROCEDURES
 Exam with contrast
 Epidural Steroid Injection
 Facet Block
 Nerve Root Block
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Esophagram
Upper GI
Lower GI
Hysterosalpinogram
 Discogram
 Myelogram
 Voiding Cystourethrogram
 Cystogram
 Retrograde Urethrogram
DEXA
 Other:________________
 Levels_________________________________
C T L
For Driving Directions, call or visit our website:
www.wcrc.com
CONVENIENT FOR ALL IMAGING NEEDS
IRVINE
16300 Sand Canyon Ave.
Irvine, CA 92618
Diagnostic Center-Suite #102
Phone: (949) 753-0900
West Coast Breast Center-Suite #203
Phone: (949) 753-9090
West Coast PET Center-Suite #103
Phone: (949) 753-0362
LAGUNA NIGUEL/
MISSION VIEJO
27882 Forbes Road
Suite #120
Laguna Niguel, CA 92677
Phone: (949) 272-2200
SANTA ANA / TUSTIN
1100-A North Tustin Ave.
Santa Ana, CA 92705
Phone: (714) 835-6055
SANTA ANA / SOUTH COAST
2620 S. Bristol St.
Santa Ana, CA 92704-5727
Phone: (714) 966-0904
ANAHEIM
1085 North Harbor Blvd.
Anaheim, CA 92801
Phone: (714) 300-0703
WCRC is contracted with most insurance carriers. Call for more information.
Revised 03/10/10
Adult Patient Preparations
Please call WCRC:
• For child/pediatric preparations
• If you are or may be pregnant
• If you have any questions
Barium Enema:
•Pick-up prep kit from WCRC at least 48 hours before exam time.
•Follow all directions on kit.
Computed Tomography (CT/with Contrast):
•Please call WCRC if you are diabetic or are known to have allergies
•In some instances, a preparation is required.
•WCRC will instruct you if a preparation is necessary.
•Creatinine/BUN required for CT within 90 days if 60 or older, renal
insufficient, diabetic or hypertensive.
DEXA:
•Patients should not be scheduled within two weeks of any diagnostic
or CT exam utilizing Barium or any nuclear medicine exam.
HSG (Hysterosalpinogram/Hysterosalpinography):
•Nothing to eat or drink 4 hours prior to exam.
•Should be scheduled 7-10 days from the start of menstruation.
IVP (Intravenous Pyelogram):
•Pick-up prep kit from WCRC at least 48 hours before exam time.
•Follow all directions on kit.
•Please call WCRC before your exam if you are diabetic or
allergic to iodine.
Magnetic Resonance Imaging (MRI):
•If you have a pacemaker, metallic implant, previous brain surgery,
or have had metal fragments in your eyes, or known allergies to
Gadolinium; please call WCRC prior to appointment time.
•Creatinine/BUN required for MRI within 45 days if 60 or older, renal
insufficient, diabetic or hypertensive.
•No preparation is required unless sedation is needed.
Mammogram:
•Do not wear perfume, deodorant, or powder the day of exam.
If new patient, bring previous mammogram films and report.
•Please wear two piece clothing.
•Do not schedule one week before menstrual period.
•Preparation for Breast Biopsy:
•No aspirin or “blood thinner” one week prior to biopsy.
•Please consult your physician prior to discontinuing medications.
Nuclear Medicine:
•Preparation varies, please direct questions to our
Nuclear Medicine Dept.
PET/CT:
•Do not eat or drink anything for 6-12 hours prior to your exam,
except water.
•Avoid strenuous activity 24 hours in advance of your study.
Ultrasound:
Abdomen Ultrasound:
•Nothing to eat, drink or smoke after midnight.
•No breakfast, smoking or gum chewing the morning of exam.
OB and Pelvic Ultrasound:
•1 hour before exam time, empty your bladder and drink
32 oz. of water, finishing 1 hour prior to exam.
•Arrive with a very full bladder. Do not urinate.
•Pelvic ultrasound should not be scheduled during menstruation.
Prostate Ultrasound:
•Fleet’s enema 1½ hour prior to exam.
Upper GI and/or Esophogram and/or Small Bowel Series:
•Nothing to eat, drink or smoke after midnight.
•For small-bowel series, allow at least 4 hours for exam.
Serving the Community
Since 1988
It’s Time To Re-Order
Referring Physician
Date_ ______________
Name__________________________________________________
Specialty________________________________________________
Contact Person_ ___________________________________________
Office Phone Number_ _______________________________________
Fax Number______________________________________________
Email Address_____________________________________________
Location
1. ___________________________________________________
___________________________________________________
2. ___________________________________________________
___________________________________________________
Do you need Diagnostic X-Ray RX Pads?
 Yes
 No
Qty___________
Do you need Breast Imaging RX Pads?
 Yes
 No
Qty___________
Please complete and Fax Request to: 714-285-1293
or Mail to:
West Coast Radiology Marketing Dept.
1100-A N. Tustin Avenue
Santa Ana, CA 92705